Las Vegas—Building an electronic alert into provider order sets can significantly improve rates of venous thromboembolism (VTE) prophylaxis, pharmacists at Mercy Hospital in Chicago have found.

Michael Mikrut, PharmD, a clinical pharmacist in internal medicine, reviewed the records from all August 2009 admissions to two nursing units of their community teaching hospital to determine if VTE prophylaxis was ordered for medical-surgical patients by the end of their second hospital day. In a presentation at the American Society of Health-System Pharmacists 2012 Midyear Clinical Meeting, he said that he found overall rates of VTE prophylaxis to be 77%, with a big gap between patients covered by medical residents (prophylaxis rate of 89%) and those not covered by residents (prophylaxis rate of 65%).

Dr. Mikrut, Sonali Muzumdar, PharmD, an informatics pharmacist, and others at the hospital formed a multidisciplinary committee to improve compliance in ordering VTE prophylaxis. In January 2011, Dr. Muzumdar created an electronic alert that fires for prescribers when they sign orders that do not include VTE prophylaxis. The alert allows physicians either to order prophylaxis or to explain why they felt it was inappropriate at that time. Pharmacy staff, nurses and auditors can review the results easily. The reasons for forgoing prophylaxis are built as orders with an expiration of 24 to 48 hours. Once the order expires, the alert will fire for providers when they order anything for the patient and VTE prophylaxis is still absent. Providers can bypass the alert in an emergency, but they will continue to receive the alert every time they place orders for the patient until they select a reason or order the prophylaxis.

“We get a lot of alerts,” Dr. Muzumdar said, “so we had to make sure this was user-friendly.” Initially, many physicians were bypassing the alert, but with some education, compliance improved, she said.

The alert was made available in May 2011 to all units except for pediatrics, OB/GYN and hospice. Six months later, the team again looked at prophylaxis rates for the initial two nursing units, finding the rates had increased to 94%. VTE prophylaxis compliance increased to 96% among patients with medical resident coverage, and to 92% among patients not covered by residents (P<0.05).

A Similar Initiative

Edith Nutescu, PharmD, a clinical professor of pharmacy practice at the University of Illinois at Chicago College of Pharmacy, said she and her colleagues employed a similar method in 2006 to improve VTE prophylaxis rates at the University of Illinois Medical Center. A task force created a VTE risk assessment form, which clinicians must complete when placing an order through the hospital’s CPOE system. In work published in the American Journal of Health-System Pharmacy (2010;67:1265-1273), Dr. Nutescu and her colleagues showed that the rate of pharmacologic VTE prophylaxis increased from 25.9% to 36.8% after implementation of the form (P<0.0001). The overall rate of VTE for the hospital did not change significantly, but a significant reduction occurred among patients on medical units, from 0.55% to 0.33% (P=0.02). There was no increase in bleeding events.

“Obviously the goal is to treat everyone at moderate to high risk [for embolism], but ultimately we want to see that prophylaxis works,” said Dr. Nutescu, director of the medical center’s Antithrombosis Center. “Electronic alerts are an effective way of increasing provider orders, increasing prophylaxis and decreasing patient events.”


Drs. Mikrut, Muzumdar and Nutescu reported no relevant financial conflicts of interest.